Simplification of first-line antibacterial regimen for complicated appendicitis in children is associated with better adherence to guidelines and reduced use of antibiotics

Abstract

Acute appendicitis in children requires early surgery and short-course antibiotics active against Enterobacteriaceae and anaerobes. Although an aminoglycoside-containing three-drug regimen has been used successfully for decades, simpler regimens with similar efficacy are increasingly used. This study evaluated the impact of a switch from the combination of cefotaxime, metronidazole and gentamicin (regimen 1) to piperacillin/tazobactam (regimen 2) as first-line regimen for complicated acute appendicitis in children. In total, 171 children were enrolled [median (IQR) age, 10 (6-13) years], treated with regimen 1 (n = 80) or regimen 2 (n = 91) following surgery for complicated acute appendicitis. The two groups were comparable except for surgical approach (through laparoscopy in 46% vs. 88% for regimens 1 and 2, respectively; P < 0.001). Post-operative complications and duration of hospital stay were similar. Deviations from antibacterial treatment protocol decreased from 36% (29/80) to 14% (13/91) (P < 0.001), with a dramatic reduction in antibacterial treatment duration from median (IQR) of 15 (12-16) days to 5 (5-8) days (P < 0.001). Post-operative intra-abdominal abscess developed in 32 children (18.7%). Female sex (OR = 2.76, 95% CI 1.18-6.48; P = 0.02) and sepsis/septic shock on admission (OR = 4.72, 95% CI 1.12-19.97; P = 0.035) were independently associated with post-operative intra-abdominal abscess, but not antibacterial regimen. This study shows that simplification of first-line antibacterial regimen for complicated appendicitis in children was associated with reduced protocol deviation, reduced duration of antibiotics, and similar outcomes (post-operative complications and duration of hospital stay).

Evidence-based optimisation of empirical antibiotic regimens in paediatric complicated appendicitis: a retrospective study of 94 patients

“…Complicated appendicitis was present in 17% of patients with a postoperative infectious complication rate of 12%, a decrease of 3% and 4%, respectively, versus the previous cohort. These rates are on the lower limit of those published, ranging from 15-40% for complicated appendicitis and 4-20% for postoperative infectious complications [14,20,23,31,32]. These favourable rates could be due to our definition of complicated appendicitis, which may differ from other institutions.…”

“…The results are often conflicting. Some authors report positive outcomes such as a decrease in the percentage of postoperative infectious complications rates in those receiving broader antipseudomonal antibiotics [42], whereas others report no added advantage [19,31,43]. These studies have many drawbacks, notably not detailing the local microbiology and thus the infection rate of P. aeruginosa.…”

“…Reverting to a triple EAR could increase morbidity, which in our view is not recommended. The risk of multidrug resistance and supplemental side effects such as infection with Clostridium difficile are important to consider when deciding to implement piperacillin-tazobactam as a first-line regimen [13,25,31].…”

Complicated acute appendicitis in children: the importance of stewarding antibiotic prescriptions

“…9 Secondly, treatment-related stress among children and caregivers should be reduced by the introduction of a simplified empirical antibiotic regimen. 23 Indeed, a decrease in intravenous infusions per day might avoid the necessity of central line insertion and multiple venous cannula replacements. For these reasons, new single-drug protocols consisting of a broadspectrum beta-lactamase or a carbapenem have been successfully introduced.…”

Bacterial peritonitis in paediatric appendicitis; microbial epidemiology and antimicrobial management

“…In our local organisation, we combine an aminoglycoside (gentamicin) with co-amoxiclav (or cefuroxime plus metronidazole in penicillin intolerant patients) to extend antibacterial coverage for common Enterobacterales resistance mechanisms and for antipseudomonal activity. Alternative options may include using antipseudomonal beta-lactams [ 17 , 18 ].…”